Dr. Lisa Freitag is a former pediatrician in Minneapolis, Minnesota. She wrote some guest posts for us in 2013, and we are delighted to have more of her insightful presence here. This is the second half of the third (and last) part: Part 3a is here; Part 2 is here; and Part 1 is here. Part 3b has been reposted from its original posting due to technical problems.

According to Arthur Frank, whose academic theories on the doctor-patient relationship began to crystallize in his book about his own illnesses, At the Will of the Body, doctors are not really caregivers. This seems counter-intuitive, since medicine is supposed to be the most caring of professions. However, doctors do not know how to act towards their patients as persons. Frank states “I reserve the name “caregivers” for the people who are willing to listen to ill persons and respond to their individual experience.” (48) His own doctors, he says, rarely did this, instead dealing with him merely as a malfunctioning body in need of repairs. If doctors relate only superficially with others in illness, they seem unlikely to have a template for dealing with themselves as patients either.

These misconceptions are perhaps ultimately destructive to the formation of a human relationship between doctor and patient, no matter which side of the relationship he finds himself on. This is demonstrated well in the opening chapter of Sherwin Nuland’s famous book, How We Die, where he reports his first encounter with death. The patient was a middle-aged man who died of a massive heart attack while the young Dr Nuland was examining him. Nuland goes to great lengths to convince the reader and himself that it wasn’t his fault. He does this, not by grieving at human mortality, but by transferring the blame to the patient. Nuland’s description of the dead man and the destructive life style that brought him to his early death, borders on hatred. Nuland describes the man’s “flabbiness,” his “gluttony,” his laziness at taking a sedentary desk job, and compares this “high pressure boss of large, tough men” to his own 22 year old “boyishness.” Though he admits that these were not known risk factors at the time, these are disdainful words that imply a sinful life. The man was ultimately responsible for his own demise, not because he is mortal, just as Dr Nuland is, but because he lived in wrongness.

Arthur Frank sees illness as a chance to witness the mortality which we all share. Instead of recognizing, and perhaps mourning, their common humanity, Dr Nuland distances himself by describing the man’s shameful life-style. One can assume that Nuland himself does not do all those naughty things, and can therefor believe he himself is safe from such a death. He spends the rest of the chapter, and indeed the book, describing in detail the ways in which the body can betray its owner, always with the idea that this knowledge, applied scientifically, will prevent death. I suspect that Dr Nuland’s own death will come (came?) as quite a surprise to him.

It is far easier to blame the wrongheaded patient rather than mourn the fact of death. Indeed, we were taught in medical school that mourning is out of place. We were supposed to create an emotional distance between ourselves and our patients. This was called maintaining objectivity, and is, we understood, a necessity, if one is to be a rational scientist. As Frank has recognized in At The Will of the Body, this distancing leads to thinking of patients as merely broken engines in need of repair. The person inside is largely ignored, except as the means which medical instructions will be carried out. The person, submitting to the will of the medical system, becomes a compliant body.

So what is a doctor to do when his own body escapes control and betrays him to illness? He must resent not only the sudden possession of a now-defective body, but also struggle to find a place to shift the blame for its failure. He must either accept that, like his patients, he might be mortal, or work to forget that medicine is not infallible. At the same time, he must willingly subject himself to becoming a body in the eyes of his peers.

All of these things are in operation when I become a patient, though I have, so far, not had a fatal one. I am surprised to find myself unprotected from sickness, and feel angry because I can’t think what I might have done to deserve it. Having at times seen illness as Dr Nuland does, as a sign of weakness in others, I find it nearly impossible to forgive it in myself. At the very least, I have failed to exert proper control over my body. It doesn’t help that I know precisely what has gone wrong, what that failure might lead to, and how painful it is likely to be to attempt to correct it.

Which is why, at the six week follow-up visit after surgery to fix my broken arm–which I honestly considered skipping altogether–I was completely inappropriate. I was annoyed that I was there, reluctantly complying with an unnecessary recommendation. My fractures were healing quite well, due to hard exercise and the help of some very good physical therapists. The orthopedic surgeon seemed inordinately pleased at his success with my operation, as though he still considered my arm partly his possession.

At one point, he told me, as though imparting a special confidence to a fellow doctor, that he liked the outcome so much that he was going to use the same “surgical approach” more often. It seems that he had put the incision on my shoulder in a different spot than usual. This was because he didn’t want to bother moving my unresponsive body between the surgery on my elbow and shoulder. I managed, just barely, to avoid saying what I was thinking, which was that this seemed terribly lazy to me. He looked, briefly, a bit confused by my horrified silence. Then he relaxed. He didn’t say anything, but he might have been thinking, Oh, right! Doctors are terrible patients. There was a small, indulgent chuckle.

I guess I was supposed to display more gratefulness. Or less implied skepticism at his talents. I feel kinda bad about this, but not bad enough to come back, as he wants me to, in another six weeks, so he can further admire his handiwork.

2 Responses to “At the Will of the Body, Part 3b: Doctors as Patients”

Sherwin Nuland died earlier this year. Here’s his obit in the NY Times, which I personally found moving. I read How We Die around when it came out, and found it worthwhile, though I think today I would also be bugged by the patient-blaming aspect you call out.